iPads and Cancer; Clot Retrieval and Stroke: It's PodMed Double T!

Podcast reviews some of the week's top medical stories

PodMed Double T is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week. A transcript of the podcast is below the summary.

This week's topics include mortality statistics since 1980 across the US, domestic healthcare costs, an iPad intervention for colorectal cancer screening, and real world experience with clot retrieval in stroke.

Program notes:

0:40 An iPad intervention for colorectal ca screening

1:40 I need colorectal cancer screening

2:42 Hopefully hooked into having screening

3:02 Real world experience with clot retrieval after stroke

4:03 Lower complication rate

5:05 Patterns of mortality relative to substance abuse and self harm

6:08 This data helpful, county by county

7:03 Rural area more problematic

7:15 Medical costs in the US

8:15 Why costs so high?

9:15 Just prolong a few months

10:11 End

Transcript:

Elizabeth Tracey: Another sobering survey of mortality across the U.S.

Rick Lange, MD: Stroke therapy in real-world conditions.

Elizabeth: Using an iPad to increase colorectal cancer screening.

Rick: And healthcare spending in the United States.

Elizabeth: That's what we're talking about this week on PodMed TT, your weekly look at the medical headlines from Texas Tech University Health Sciences Center at El Paso. I'm Elizabeth Tracey, a medical journalist at Johns Hopkins, and we're posting this on March 16th, 2018.

Rick: I'm Rick Lange, President of the Texas Tech University Health Sciences Center at El Paso and Dean of the Paul L. Foster School of Medicine. Good morning, Elizabeth.

Elizabeth: Good morning, Rick. It's great to see you. I think we should start first with Annals of Internal Medicine. We went back and forth, before we started to record, just a little bit about this. There are actually two studies in Annals, but the one that I picked was the one relative to use of iPads to get people to think about colorectal cancer screening and then to schedule themselves. This amazing study, I thought it was amazing because, of course, it also gives folks something to do while they're sitting around in the waiting room.

There were 450 patients in the study, half of whom got an iPad. The iPad had a video that talked about colorectal cancer screening, and then enabled the patient to actually order their own screening test and sent an automated follow up to support them to go forward and do that. The other folks just got the normal intervention, "Hey, maybe you should consider this." It turned out when they took a look at the rate of scheduling, 100% more people actually scheduled if they were given the iPad in order to come up to this idea of, "Hey, I really need colorectal cancer screening." I thought that was amazingly impressive.

Rick: Probably the part that I thought was really impressive, Elizabeth, that of the individuals that were participating in the study, more than a third of them had very limited health literacy and half of them were in the poverty level. This is a particular group of individuals. It's very hard to get the message out to of how important colorectal cancer screening is and to actually get them to do it. To double their involvement, it's actually pretty remarkable. It really costs pennies on the dollars to do it.

Elizabeth: I guess we would both conclude that and think it ought to be promulgated out there for other folks. In the other study that's also in Annals, gosh, in a VA population, a really impressive result with regard to reduction of colorectal cancer deaths.

Rick: That is that the individuals that had colorectal cancer screening using colonoscopy, it decreased their risk of colorectal cancer by about 60%.

Elizabeth: I guess our follow up here would be what, if you were going to put it together into a public health message?

Rick: For all of our listeners, hopefully we've hooked you into the importance of having colorectal cancer screening, and the other is for our healthcare providers is the use of what I'm going to call "low-cost technology" to help increase colorectal cancer screening rates.

Elizabeth: Excellent. Let's turn from here to the British Medical Journal, since we're talking about things that are practical. In this case, this is the study where they took a look at, "Wow, if we go in and retrieve a clot when someone has a stroke, which we've done in lots of studies and proven its efficacy, how well does it work?"

Rick: This is called endovascular treatment for acute ischemic stroke, and we know that if you can do that early enough you can have a fairly good neurologic outcome. Randomized control trials have shown that this endovascular treatment improves neurologic outcome, but you know many of the people in these randomized trials aren't the real-world kind of people that we treat. The nice thing about this particular trial is it takes the randomized trial and then extends it into a real-world setting to see if the results are as good -- and frequently they're not, but in this particular study, they were.

They looked at almost 1,500 patients presented with a stroke. They documented they had a thrombus or a clot, then they prescribed endovascular treatment. The outcome was just as good. Actually, it was a little bit better. They had more people that had an excellent or good neurologic outcome and a lower complication rate.

Elizabeth: I think there's a couple things that are worth noting about the endovascular therapy. You need somebody who really knows what they're doing, and so I think it argues very strongly for specialized stroke centers to which patients will be transported when they present with a stroke. The other thing is the imaging that's also really important in order to establish this.

Rick: In fact, in this particular trial, even though the patients were older and had more comorbidities, more diseases, and you'd think they wouldn't do as well as a randomized trial, they actually had the procedure done an hour earlier than the randomized trials. That's just because of what you described. Good imaging, expert people experienced with the technique.

Elizabeth: Then let's end by offering, again, a public health statement to anyone who's listening to this. If you think you're having a stroke, don't think it's going to go away. Seek treatment right away.

Rick: Absolutely. As you said, the acute stroke care centers deliver the best care.

Elizabeth: Okay. I guess now we're going to need to move on to the sobering ones for this week, at least I think they're fairly sobering. Both of them [were] in the Journal of the American Medical Association. One of them taking a look at patterns of mortality relative to substance-use disorders and intentional injuries from 1980 until 2014. We have talked very much about this in the past, and in fact, we took a look at the last study that also captured this data. But this one looks at almost 3 million deaths that have taken place in the United States during this time period, taking a look at the substance-use disorders as well as alcohol-use disorders, self-harm, and interpersonal violence.

Not surprisingly, of course, almost 620% increase in drug-use disorder deaths. Also, though, for a while, it was looking like self-harm was going down and now it's going back up. What's useful about this data, of course, is it pinpoints certain areas in the United States where these things are true. The self-harm, specifically firearm-related death, much higher and going up in the U.S. West, so clearly giving people targets for intervention.

Rick: Yep, in my opinion, that's why this data is particularly helpful. It does it county by county. As you note, overall there was a marked increase use of deaths due to drug abuse, but it's really concentrated in certain areas in the United States. We can focus on these particular areas, for example, in the Appalachian areas, where we need to direct our resources to this. So interdiction alone won't help. It really is a multi-pronged attack.

Elizabeth: I'd have to say I agree with that idea, also, with regard to treatment because simply providing folks with naloxone isn't going to do the trick. They need the whole constellation of support and behavioral intervention and jobs and financial security. I mean I think it's fairly easy to take a look at the constellation of things and say, "It is very much a multi-pronged approach that's needed."

Rick: You're right. Those areas where opioid abuse is particularly problematic isn't in the large metropolitan areas. It's in the rural areas. There's a low socioeconomic status, a low literacy rate, and a very high unemployment rate as well. So this is a social problem.

Elizabeth: Let's transition, then, to the other study that's also in JAMA taking a look at, "Wow, we spend an awful lot of money on healthcare, but we don't seem to be getting the bang for the buck."

Rick: Elizabeth, this was particularly timely. I'm actually in Dallas where I was speaking at the International Financial Conference. These are bankers from around the world and we were talking about healthcare spending in the United States compared to other high-income countries where these bankers come from. In 2016, the United States, according to this study, spent almost 18% of the gross domestic product on healthcare. It ranges from about 9.6% in Australia to a high of 12.4% in Switzerland, so we're much higher and it's been increasing over the last several decades.

These other countries have about 99% to 100% of their individuals insured. We have about 90%. Compared to the other countries, we have a lower rate of smoking, but a higher rate of people being overweight or obese, about 70%. Our longevity is the lowest of all of these countries, and we have a higher infant mortality rate. Why is our cost twice as much as other countries? Pharmaceutical cost that's two to three times higher than in other countries. Salaries for healthcare providers is about twice as high, and we use more imaging.

Elizabeth: I see that you included in that whole thing the physicians' salaries. I think that's something that's worth landing on somewhat because a lot of studies don't identify that as one of the major drivers, but this one does.

Rick: It's interesting. When you look at salaries per healthcare provider, we're twice as high in other countries. On the other hand, we have half as many. So the overall total cost is the same across all countries. Where we're really behind in other countries is pharmaceuticals. We have not given the federal government the ability to regulate pharmaceutical costs. Only about 20% of our volume is with brand drugs, about 60% to 70% of the cost is due to them. Where I want to really focus on just for a second is the cost of cancer therapies now. These are drugs that don't put the cancer into remission. They just prolong the life for an extra, maybe, 3 months at the cost of several hundred thousand dollars.

Elizabeth: I would add also on this drug-cost note that Martin Shkreli was just sentenced or indefensible manipulation of the marketplace.

Rick: For our listeners, this was the head of a pharmaceutical company that took over a generic medication, a one-of-a-kind, and raised the price by 6,000%, not to recover any R&D costs, but simply for greed. The Securities and Exchange Commission got him for fraud and abuse, and he'll spend at least 7 years behind prison [bars] and a $17.5 million asset [forfeiture] as well.

Elizabeth: Well, I certainly am going to advocate for the federal government being able to negotiate drug prices. On that note, I'm going to talk about the iPad intervention this week on the blog. That's a look at the weekly medical headlines from Texas Tech. I'm Elizabeth Tracey.

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